Christopher has suffered from migraines since he was 2. He experiences insomnia that leaves him to roam his home throughout the night.

The way he manages the conditions, however, has caused him to run afoul of his medical provider’s rules and leaves him facing a tough decision: treat his migraines or treat his insomnia.

Christopher is a Camas man in his 50s. He is married, runs his own business and volunteers in the community. The Columbian is not using his real name, at his request, to protect his identity as he attempts to navigate the gray area between the legal use of prescription opioids and provider-recommended medical marijuana.

Christopher has a prescription from his doctor for Norco, a hydrocodone/acetaminophen combination similar to Vicodin that is used to relieve pain. He uses the 15 pills, which is about seven doses, prescribed each month when his migraines can’t be controlled by Excedrin or Tylenol with codeine.

He also has a written recommendation from a naturopath to use marijuana to manage his insomnia. Providers cannot prescribe marijuana but can advise qualifying patients that they may benefit from the medical use of marijuana.

While Christopher acquired both medications through the appropriate channels, his use of marijuana is prohibited by his medical provider. As a result, Christopher’s provider will not refill his Norco prescription.

“People need to know that they may be forced to make a decision about what ailments they want to treat if they start using marijuana,” Christopher said. “I’m forced to choose whether to treat my insomnia or my headaches.”

Medical providers, however, say balancing prescriptions for controlled substances and a patient’s decision to use marijuana is tricky and can be dangerous for the patient.

“It’s a really difficult issue,” said Dr. Marcia Sparling, a medical director at The Vancouver Clinic.

Treatment plans

State law requires pain medication prescribers to use written treatment plans and agreements with patients. State law does not, however, specify requirements to be included in the agreements and doesn’t address the use of other drugs, such as marijuana.

That means they can, and do, vary from provider to provider.

In Clark County, Kaiser Permanente and Legacy Medical Group prohibit pain patients from using marijuana or other drugs. Their treatment plans indicate a patient can lose their prescription for pain medication if they test positive for marijuana.

The Vancouver Clinic, however, doesn’t have such a hard-and-fast rule. Their pain treatment plans require urine drug screening, but whether a positive test means a patient will lose their prescription is left to the physician’s discretion, Sparling said.

Officials at Kaiser, Legacy and The Vancouver Clinic all said the treatment plans are used to keep patients safe and ensure the powerful and potentially addictive pain medications are being used appropriately.

The agreements define expectations of both the patient and provider, identify the risks of using the prescription drugs and outline how providers will ensure patients are complying with the rules of the agreement.

At The Vancouver Clinic, physicians are encouraged to use their best medical judgment when it comes to prescription pain medication and marijuana use, Sparling said.

“We have never mandated that doctors must cut someone off if marijuana shows up on a urine drug screen,” she said.

Instead, physicians have to determine whether they believe the patient’s marijuana use will interact or interfere with the prescribed medication, Sparling said.

Some physicians are strict; they don’t ever believe a patient should be using marijuana and pain medication. Others are more flexible, depending on the quantity of marijuana and prescription drugs, Sparling said.

At Kaiser, the treatment plans require patients to abstain from other drugs, said Dr. Brad Anderson, chief of addiction medicine at Kaiser Northwest.

If a patient who has signed a treatment plan tests positive for marijuana, he or she will lose their prescription, Anderson said. That’s been the standard and will continue to be the standard — regardless of whether marijuana use is legal, he said.

“They have the right in Washington state … to possess and smoke it, but the doctor maintains the right to determine what is the best medication for them,” Anderson said.

“You can choose how to treat the pain, the medications we provide, or the marijuana you obtain,” he added.

Legacy Medical Group also prohibits patients using prescribed controlled substances from using any illegal or recreational drugs, including marijuana, said Brian Willoughby, Legacy spokesman. Providers are concerned about the potential interaction between marijuana and prescribed drugs, he said.

Failed drug test

Christopher has been using Norco since he was a teenager. Last spring, his provider at Kaiser Permanente asked him to sign a pain management plan. At the time, Christopher wasn’t using marijuana and had no intention of trying it, so he signed the contract without a second thought.

About six months later, however, a friend of Christopher’s suggested he try using marijuana before bed to help with his insomnia. Christopher had been taking Ambien for years, but the drug was no longer effective.

Christopher tried marijuana despite a warning from his physician that the drug could show up on a urine screening and cost him his Norco prescription. He found the marijuana to be more effective at helping him sleep than Ambien. So every night before bed, Christopher takes three or four inhalations of marijuana from a small vaporizer, similar in appearance to an electronic cigarette. A gram of marijuana lasts about two weeks, he said.

“This has worked well for me,” he said. “It helps me relax right before bed.

But this spring, Christopher’s doctor asked him to submit to a urine screening, per his treatment plan, in order to receive a Norco prescription renewal.

Christopher had been using marijuana, so he decided to wait until he returned from his planned 2½-week vacation to take the test. He didn’t use marijuana while on vacation, and when he returned home, decided to purchase an at-home urine screening test to make sure the marijuana was no longer detectable in his system.

The test came back positive.

Two months later, after multiple failed at-home tests, Christopher went to Kaiser for his urine screening. He had been relying on unused pills from earlier prescriptions to manage his migraines in the interim, but he was running out. He needed a new prescription.

He was also tired of not sleeping. Christopher had been taking shots of rum before bed in attempt to get the same calming affect he got from marijuana. The alcohol wasn’t working.

Despite not using marijuana for two months, Christopher still tested positive and his doctor refused to refill the Norco prescription.

Frustrated, Christopher resumed using marijuana before bedtime.

“I gave up on trying to meet what seems to be an impossibly high standard,” Christopher said.

He recently submitted another urine sample for screening. The urine didn’t belong to Christopher. He’s still awaiting the results.

In the meantime, Christopher ran out of Norco. Friends and family members aware of his situation have given him some of their prescription pain medication to help with his migraines.

Christopher acknowledges his drug testing methods are dishonest and the prescription drug sharing is illegal. But, he said, the situation illustrates the lengths he has to go in order avoid choosing which condition to treat and which to leave untreated.